优先精准解剖肾上腺中央静脉在后腹腔镜肾上腺肿瘤切除术中的应用

目的 探讨后腹腔镜优先精准解剖肾上腺中央静脉在肾上腺肿瘤切除术中的应用价值。方法 回顾性队列研究。纳入2014年3月—2018年10月徐州医科大学附属淮安医院行后腹腔镜肾上腺肿瘤切除患者76例,其中男41例、女35例,年龄33～67(42±11)岁,左侧42例、右侧34例。按手术方式不同分为两组,其中采用传统“三层面法”的患者纳入传统组(38例),采用术中优先精准解剖肾上腺中央静脉后再游离肾上腺的患者纳入精准解剖组(38例)。比较两组患者手术时间、术中出血量、腹膜后引流管留置时间、肠蠕动恢复时间、住院时间及术后并发症等。结果 两组患者年龄、性别构成、体质量指数(BMI)、肿瘤位置、肿瘤类型和平均直径等基线资料比较,差异均无统计学意义(P值均＞0.05)。两组患者均顺利完成手术,无中转开放手术者。患者术后均获得随访6~24(18.5±4.5)个月,未见肿瘤复发及转移。传统组手术时间、术中出血量、留置引流管时间、肠蠕动恢复时间和住院时间分别为(61.4±15.9)min、(66.84±19.25)mL、(3.6±0.6)d、(1.8±0.3)d、(7.9±2.1)d,精准解剖组分别为(66.2±13.7)min、(50.34±15.66)mL、(2.2±0.4)d、(1.7±0.3)d、(6.2±1.4)d。精准解剖组术中出血量、留置引流管时间、住院时间均少于传统组,差异均有统计学意义(t=4.099、11.396、3.990, P值均＜0.05);两组手术时间、术后肠蠕动恢复时间比较,差异均无统计学意义(P值均＞0.05)。两组患者在术后均未见肾上腺危象、皮下气肿、高碳酸血症等严重并发症发生。结论 后腹腔镜肾上腺肿瘤切除,术中优先精准解剖肾上腺中央静脉并结扎,具有出血少、手术视野清晰,安全性高,值得进一步深入研究。     

腹腔镜肾上腺外科在儿童中的应用

目的　 1992年首次报告了腹腔镜肾上腺切除术 ,此后有 4 0 0余篇关于数百名成人在此方面的研究文献公开发表。儿科腹腔镜肾上腺切除报告较少 ,因此我们回顾腹腔镜肾上腺外科在儿童的应用经验。资料与方法　 1994 .12 - 2 0 0 1.0 8成功应用腹腔镜肾上腺切除术 13例 ,其中女孩 8例 ,男孩 5例 ,年龄最大者 15岁(平均 6 .3岁 )。术前临床诊断肾上腺生殖器综合征 5例、无功能肾上腺肿瘤 3例、库兴氏综合症 2例、嗜铬细胞瘤 2例、库兴氏病 1例。CT显示单侧肾上腺病变大小 15 - 80 m m(平均 4 1.4 mm)。结果　 13例中有 2例改为开放手术 (15 .4 %…     

经腹膜后间隙入路腹腔镜肾及肾上腺手术的应用解剖

目的 探讨经腹膜后间隙腹腔镜肾上腺肿瘤切除术及肾脏手术的应用解剖及临床价值。方法 对2002年3月今开展的共58例腹腔镜泌尿手术进行分析，其中肾囊肿去顶减压术41例，肾上腺肿瘤切除术16例、肾切除术1例。结果 除1例肾囊肿去顶减压术因后腹膜控腔制备失败开放手术外，其余57例手术均获成功，手术时间肾囊肿30-120min，肾上腺70-140min，1例肾切除210min，失血量20-100ml，平均50ml，术中及术后均未输血，全部患者均无并发症。结论 经腹膜后间隙腹腔镜肾脏及肾上腺手术具有进路直接、解剖简单、易于掌握，对组织损伤小、出血少、对腹腔干扰小、术后恢复快、并发症少等优点。可作为肾上腺良性疾病及部分肾脏疾病手术治疗的首选方法。     

后腹腔镜在肾上腺手术中的应用

1资料与方法 1.1临床资料 6例肾上腺肿瘤患者,男4例,女2例,年龄38～65岁,平均47.8岁.术前根据临床症状、实验室检查、彩色多普勒超声及CT检查结果得到诊断,其中原发性醛固酮增多症3例、无功能腺瘤1例、嗜铬细胞瘤2例.肿瘤大小为2.1 cm×2.2 cm～4.3 cm×4.5 cm.     

肾静脉和肾上腺静脉插管的应用解剖

为给临床提供肾静脉和肾上腺静脉插管的应用解剖学数据,在45具成尸上,对肾静脉和肾上腺静脉的回流部性、角度、外径和长度等进行了观测。     

解剖性腹膜后间隙的建立及扩大在经后腹腔镜手术中的应用

目的探讨在泌尿外科经后腹腔镜手术中,腹膜后间隙的建立、确定及扩大对肾上腺、肾脏、输尿管等脏器疾病的手术应用。方法根据腹膜后间隙解剖学研究的层次特点,建立、确定及扩大镜下腹膜后间隙,经腹膜后方向入路,对68例肾上腺、肾脏、肾盂与输尿管等疾病患者实施腹腔镜手术治疗。结果 68例手术中顺利建立了相应的腹腔后间隙,完成了相应手术;5例发生腹膜穿破,无中转开放手术,无输血及其它严重并发症发生。结论腹膜后间隙是泌尿外科微创手术的重要入路,关键是解剖学标志、结构层次的镜下确定,间隙内具有足够操作空间、满足腹膜后泌尿外科手术、手术安全性较高、并发症少等优点。     

肾前筋膜间平面无血腹腔镜上尿路手术入路精准解剖与技巧

目的　探讨肾前筋膜间平面无血腹腔镜上尿路手术入路精准解剖与技巧（Inter-prerenal-fascia planes in urological laparoscopic operations,IpULO）。 方法　采用尸体解剖、320排CT影像解剖研究及临床病例活体腹腔镜手术研究,对IpULO手术中肾前筋膜间平面相关解剖标志在腹腔镜下的形态特点进行观察研究。 结果 肾前筋膜间平面是肾前间隙多层次的无血管筋膜结构,层面间充满蜘蛛丝网格状白色纤维组织,在IpULO手术过程中存在7个重要的外科平面：Told’t 筋膜间平面、结肠融合筋膜肾前融合筋膜间平面、结肠融合筋膜胰十二指肠前融合筋膜间平面、胰十二指肠后融合筋膜肾前融合筋膜间平面、肾前融合筋膜肾筋膜前叶间平面、肾筋膜前叶肾脂肪囊外平面、肾前肾筋膜前叶下平面。 结论 IpULO手术是基于层面外科的精准解剖入路,肾前筋膜间平面是IpULO手术的重要解剖层面,术中能推窗见景,避免解剖迷失。     

影响后腹腔镜肾上腺肿瘤切除术复杂程度的因素

腹腔镜手术切除是肾上腺肿瘤治疗的标准术式.后腹腔镜肾上腺肿瘤切除术与经腹膜入路相比具有优势,其可以更方便、直接地进入肾上腺.多项研究表明后腹腔镜肾上腺肿瘤切除术的难度与多种因素有关,肿瘤大小、患者性别、患者体重指数(body mass index,BMI)、患者肾体位肋脊间距离(12肋缘下与髂前上棘间距离)、肾上腺肿瘤...     

后腹腔镜肾上腺切除术36例报告

目的 探讨后腹腔镜。肾上腺切除术的适应证及手术方法。方法应用后腹腔镜肾上腺切除术治疗肾上腺疾病36例37侧，其中原发性醛固酮增多症12例，皮质醇增多症11例12侧，嗜铬细胞瘤9例，无功能腺瘤4例。结果36例手术均获得成功，手术时间平均90(70～210)min。术中出血平均40(20～100)ml，均未输血。患者术后1～2d恢复进食，并可下床活动。术后住院时间平均6(4～12)d。结论与开放手术相比，后腹腔镜手术具有创伤小，疼痛轻，康复快等优点，应成为肾上腺良性疾病的首选手术方法。     

超声刀在泌尿系统后腹腔镜手术中的应用

探讨后腹腔镜技术治疗泌尿系统疾病的微创方法。方法应用超声刀经后腹腔镜途径对14例肾囊肿和6例肾上腺疾病患者进行手术治疗。其中原发性醛固酮增多症4例,无功能腺瘤1例,原发性肾上腺结节状增生1例;14例肾囊肿病例中5例为单侧多发性囊肿,9例为单发性;左肾8例,右肾6例;囊肿直径25～135mm,平均62.3mm。改良了穿刺点和扩张后腹腔的方法,采用超声刀进行分离和切割。结果本组病例应用以上方法全部获得成功,无术中转开腹手术者所有患者术中、术后均未输血。手术时间30min至2.5h。术中平均出血30ml。平均住院时间5.2天。结论有效的后腹腔扩张是进行手术的关键;超声刀具有精确切割和可靠止血的优势,不产生烟雾,提高了手术效率,在泌尿系手术中具有很好的推广前景。     

Primary sarcomatoid carcinoma of the adrenal gland

Summary The first case of a sarcomatoid carcinoma of the adrenal gland is reported. The patient, a 68-year old woman, developed a recurrence two months after presentation and died of the disease 7 months later with multiple metastases. The differential diagnosis of this entity is discussed and its aggressive behaviour is emphasized.     

Myelolipoma in adenoma of accessory adrenal gland.

A tumor was incidentally found at autopsy in the vicinity of the right adrenal gland of a 69-year-old man who had died of liver cirrhosis with hepatoma. Microscopic examination disclosed a myelolipoma associated with a cortical adenoma occurring in an accessory adrenal gland. No evidence of hormonal abnormalities was found in the clinical record of the patient. The association of myelolipoma with cortical adenoma occurring in an accessory adrenal gland seems very unusual, and the present case is believed to be the first reported of this type of association.     

Immunohistochemical localization of endothelin-1 in non-neoplastic and neoplastic adrenal gland tissue

Endothelin (ET)-1 is a 21-amino acid peptide with potent vasopressor and vasocontrictive properties. Biochemical studies suggest that this peptide occurs in adrenal glands, where it influences steroid hormone production. However, we have found no report of the topographical distribution of this peptide. The localization of ET-1 immunoreactivity in non-neoplastic (37 cases) and neoplastic adrenal glands (48 cases) was investigated with a sensitive immunohistochemical technique applied to routinely processed tissue specimens. ET-1 immunoreactivity was regularly seen in the cortex, especially in the zona fasciculata and to a varying extent also in the other two zones, but not in the medulla. The immunoreactive material appeared in the cytoplasm mostly in the form of vacuolar structures but also as grains. Focally, the cell membrane also showed immunoreactive staining. In the zona reticularis the immunoreactivity appeared mainly as cytoplasmic grains. Most cortical adenomas displayed numerous immunoreactive cells. The immunoreactivity in the tumour tissue appeared in the same forms as in normal cortex, but the reactive products were generally fewer in number. No obvious differences in immunostaining were seen between the aldosterone- and cortisol-producing adenomas or the non-functioning ones. Three of the ten carcinomas contained immunoreactive cells, but they were few, appearing focally and the ET-1 immunoreactive structures were seen as dust-like material. The difference in immunoreactivity between the benign and the malignant cortical neoplasms may be of diagnostic value. Functionally our results support a relationship between ET-1 and steroid regulation in non-neoplastic cortical tissue.     

Malignant PEComa of the adrenal gland

Perivascular epithelioid cell neoplasms, also known as PEComas, are unique mesenchymal tumors exhibiting perivascular epithelioid cell differentiation, characterized by a mixed myogenic and melanocytic phenotype. PEComas arising in visceral organs outside of the kidney, liver, and lung are rare, and often pose problems in diagnosis. Examples of this neoplasm originating in the adrenal gland are limited. The present report details the clinical and pathologic features of an unusual case of a pure epithelioid PEComa (epithelioid angiomyolipoma) of the adrenal gland exhibiting clinically malignant behavior in the form of pulmonary metastases, a feature not previously described in tumors of this site. The diagnosis was supported by immunohistochemical studies demonstrating expression of myoid and melanocytic antigens. The present case serves to emphasize the potential of PEComa for clinically aggressive behavior and the importance of distinguishing this tumor from other epithelioid neoplasms that are more commonly encountered in the adrenal gland.     

Primary adrenal leiomyosarcoma: a case report and review of literature

Primary adrenal leiomyosarcoma (PAL) is an extremely rare mesenchymal tumors and originates from the smooth muscle wall of the central adrenal vein and its branches. Herein we report a case of a 49-year-old female suffering from PAL. Computed tomography revealed a well-circumscribed heterogeneously mass measuring 6×5×5 cm located in the left suprarenal areal, and a left laparoscopic adrenalectomy was underwent. Microscopic examination showed a hypercellular tumor with intersecting fascicled of spindled cells. Immunohistochemical staining showed that the cells were positive for desmin, smooth muscle actin (SMA), vimentin and negative for CD34, CD117, S100, Bcl-2 and Dog1. No oncological treatment underwent after surgery, and the patient had no recurrence or metastasis at 6 months postoperatively.     

Calcifying fibrous tumor of the adrenal gland

Calcifying fibrous tumor is an uncommon entity with distinctive pathologic features. Most calcifying fibrous tumors involve the peripheral soft tissues or serosal surfaces, with reports of visceral examples of this lesion being extremely limited. We report the clinical and pathologic features of an unusual case of calcifying fibrous tumor occurring in the adrenal gland of a 32-year-old woman. Microscopically, the lesion was well circumscribed and composed of dense, poorly cellular collagenous tissue, scattered spindle cells, an inflammatory infiltrate consisting of plasma cells and lymphocytes, and dystrophic calcifications. The morphologic diagnosis of calcifying fibrous tumor was supported by diffuse positive immunoreactivity for factor XIIIa and absence of reactivity for muscle specific actin, smooth muscle actin, and anaplastic lymphoma kinase. Although rare, awareness that calcifying fibrous tumor may occur at this particular site is important so as not to confuse this lesion with other mesenchymal neoplasms of the adrenal gland.     

γ－干扰素样物质在肾上腺皮质腺肿瘤中的表达

为了检测γ－干扰素（ＩＦＮ－γ）是否在人肾上腺组织和肾上腺皮质腺肿瘤中有表达，我们对包括瘤旁肾上腺组织１４例；肾上腺皮质腺瘤１７例；皮质腺癌７例的组织标本，用抗大鼠ＩＦＮ－γ单克隆抗体ＤＢ－１做为一抗，采用ＡＢＣ法做免疫组化染色。结果：ＩＦＮ－γ样免疫反应阳性物可在１００％（７／７例）肾上腺皮质腺癌，４７％（８／１７例）皮质腺瘤细胞内和３０％腺癌（２／７例）和腺瘤（５／１７例）组织内毛细血管内皮细胞中检出，瘤旁肾上腺组织内未见阳性反应细胞。结论：（１）ＩＦＮ－γ的存在与肾上腺皮质肿瘤的分化有关，分化越低，ＩＦＮ－γ的阳性率越高。（２）肾上腺皮质肿瘤内的毛细血管内皮细胞可能具有ＩＦＮ－γ受体或能产生ＩＦＮ－γ。另外，在肿瘤组织内还发现一些树突状ＩＦＮ－γ阳性细胞，其存在意义尚待探讨。     

Cortical-chromaffin cell interactions in the adrenal gland

Adrenal catecholamines and steroids are important regulators of the stress response, immune function, blood pressure, and energy homeostasis. Historically, the two cell populations within the adrenal gland—the steroid-producing adrenocortical cells and the catecholamine-producing chromaffin cells—have been regarded as two independent endocrine systems. Research on adrenal physiology and pathophysiology has therefore largely focused on the individual understanding of each cell type. However, adrenal cortex and medulla appear to be interwoven and show multiple contact zones without separation by connective tissue or interstitial membranes. In vitro studies, animal models, and the analysis of human adrenal pathophysiology have demonstrated critical importance of cortical-chromaffin crosstalk for adrenal function and disease. Thus, chromaffin cells regulate steroid-hormone release by the adrenal cortex and steroids induce catecholamine production in the medulla. Consequently, disorders of the adrenal cortex have been shown to affect chromaffin cell function and vice versa. Mouse models of adrenal cortical dysfunction, such as the targeted disruption of the 21-hydroxylase- or the CRHR1 genes, show alterations in chromaffin cell function, while disruption of tyrosine hydroxylase, a key enzyme in catecholamine synthesis, impairs adrenal cortical function. Accordingly, patients with congenital adrenal hyperplasia (CAH) and Addison’s disease show reduced catecholamine biosynthesis. Immense progress in characterizing the mechanisms of chromaffin-cortical interactions has been achieved in recent years. Here, we summarize the current view on intraadrenal communication with respect to adrenal pathophysiology.     

Sarcomatoid carcinoma of the adrenal gland: A case report and review of literature

Reports about adrenocortical carcinomas (AC) mixed with sarcomatous areas are very rare. The terminology and pathogenesis of such biphasic tumors remain controversial. Herein, we report a case of sarcomatoid carcinoma of the adrenal gland in a 75-year-old woman who presented with left abdominal pain of one month's standing. The results of abdominal ultrasonography and computed tomography (CT) showed the presence of a large heterogeneous adrenal mass. A left adrenalectomy and complete splenectomy were performed. Histologically, the neoplasm showed areas of adrenocortical carcinoma and areas of sarcomatoid spindle cell proliferation. When examined immunohistochemically, the carcinomatous cells stained positively for S-100 protein, Melan-A protein, and neuron-specific enolase (NSE), and focally for vimentin and the cytokeratin marker MNF 116. Also, the carcinomatous cells were immunoreactive to the monoclonal antibody HMB-45. The sarcomatous component expressed vimentin, as well as other smooth and skeletal muscle markers. Liver metastases appeared 3 months postoperatively. Twelve months after removal of the primary tumor, the patient died of her disease. To the best of our knowledge, only seven cases of adrenal sarcomatoid carcinoma have been reported in the medical literature. We review the reported cases according to the 2004 classification of the World Health Organization (WHO) of lung tumors, and highlight the histogenesis, diagnosis, and clinical course of this very aggressive tumor.